A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin?

A. The client should place a pillow under their knee when resting: Placing a pillow under the knee after surgery is generally not recommended because it can promote flexion contractures. Instead, the knee should be kept in a neutral or slightly extended position to maintain proper alignment and prevent stiffness.

B. The client should take an anticoagulant for 3 days following surgery: Anticoagulant therapy after knee surgery is typically prescribed for a longer period, often several weeks, depending on the client’s risk for deep vein thrombosis. A 3-day regimen would be insufficient for most post-operative patients.

C. The client should begin to ambulate using a walker or a cane: Early ambulation with assistive devices is a standard intervention in post-knee surgery rehabilitation. It helps maintain mobility, prevents complications like deep vein thrombosis and muscle atrophy, and promotes joint function while ensuring safety as the client regains strength.

D. The client should begin physical therapy 3 weeks after surgery: Physical therapy usually begins within 24–48 hours post-surgery or as soon as the client is medically stable. Delaying therapy for 3 weeks would hinder recovery, increase stiffness, and delay functional independence.

Rationale for correct choices

• Blood pressure: The client’s blood pressure readings are consistently elevated (162/112 mm Hg and 166/110 mm Hg), which is a hallmark of preeclampsia. Hypertension arises from abnormal placental development leading to systemic vasoconstriction. Elevated blood pressure is a primary diagnostic criterion for preeclampsia and is more directly indicative of this condition than HELLP syndrome alone. HELLP may occur without hypertension.

• Hemoglobin: The client’s hemoglobin is mildly elevated at 18 g/dL with a hematocrit of 35%, suggesting hemoconcentration and potential microangiopathic hemolysis, a component of HELLP syndrome. While preeclampsia may cause mild hemoconcentration, hemolysis is a defining feature of HELLP. This reflects red blood cell destruction associated with this syndrome.

• Alanine aminotransferase (ALT): ALT is slightly elevated at 40 units/L, reflecting liver involvement. Liver enzyme elevation can occur in severe preeclampsia due to hepatic ischemia and in HELLP syndrome due to hepatocellular injury from hemolysis and microvascular obstruction. The finding supports involvement in both conditions.

• Platelet count: The platelet count is low at 98,000/mm³, which can result from platelet activation and consumption in both preeclampsia and HELLP syndrome. Thrombocytopenia is a hallmark of HELLP syndrome and may also develop in severe preeclampsia. This finding indicates increased risk for bleeding and warrants prompt intervention and monitoring.